Unique Plan Description: Comfort Care EKM
Plan Selection Display: Comfort Care
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-04-20 11:45:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-08-30 10:36:59
Available at all facilities: No

Comfort Care EKM
Admit/Discharge/Transfer
	Comfort Care Status
		T;N
			Comment: initiate Nursing comfort care plan, and provide comfort care cart and education packet to family/door hanger
	Resuscitation Status
		No Code
		Full Code
Vital Signs
	Vital Signs
		Q12H-Sch
			Comment: Or as requested by family.  Do not disturb patient for routine vital signs.  No automatic blood pressures. Use manual cuff only.  Discontinue Pulse Oximetry. Routine assessments and screening to q12h and prn based on comfort needs or as desired by family
	Discontinue
		T;N, Daily weights
Activity
	Up with Assistance
		As desired by patient
	Activity-As Tolerated
		
Diet
	Regular Diet
		T;N
			Comment: As tolerated and desired by patient
	Discontinue Enteral Feeding
		
Medications
Pain/Dyspnea
		Opioids are the mainstay of treating pain and dyspnea. UpToDate recommends a short acting oral/sublingual opioid, usually morphine in the liquid concentrate form (20 mg/mL). Because patients who need opioids for symptom control may be unable to request th(NOTE)*
		Scheduled(NOTE)*
	MS Contin
		15 mg, Tab, By Mouth, Q12H
			Comment: for pain or dyspnea
		30 mg, Tab, By Mouth, Q12H
			Comment: for pain or dyspnea
		45 mg, Tab, By Mouth, Q12H
			Comment: for pain or dyspnea
		60 mg, Tab, By Mouth, Q12H
			Comment: for pain or dyspnea
	oxyCODONE extended release
		10 mg, Tab, By Mouth, Q12H
			Comment: for pain or dyspnea
		20 mg, Tab, By Mouth, Q12H
			Comment: for pain or dyspnea
		30 mg, Tab, By Mouth, Q12H
			Comment: for pain or dyspnea
		40 mg, Tab, By Mouth, Q12H
			Comment: for pain or dyspnea
	HYDROmorphone oral
		1 mg, Tab, By Mouth, Q4H
			Comment: for pain or dyspnea
		2 mg, Tab, By Mouth, Q4H
			Comment: for pain or dyspnea
		3 mg, Tab, By Mouth, Q4H
			Comment: for pain or dyspnea
		4 mg, Tab, By Mouth, Q4H
			Comment: for pain or dyspnea
	morphine  oral immediate release
		7.5 mg, Tab, By Mouth, Q4H
			Comment: pain-breakthrough
		15 mg, Tab, By Mouth, Q4H
			Comment: pain-breakthrough
		30 mg, Tab, By Mouth, Q4H
			Comment: pain-breakthrough
	dexAMETHasone
		4 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: for pain or dyspnea
		8 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: for pain or dyspnea
		10 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: for pain or dyspnea
		12 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: for pain or dyspnea
		16 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: for pain or dyspnea
		20 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: for pain or dyspnea
		4 mg, Tab, By Mouth, NOW
			Comment: for pain or dyspnea
		8 mg, Tab, By Mouth, NOW
			Comment: for pain or dyspnea
		10 mg, Tab, By Mouth, NOW
			Comment: for pain or dyspnea
		12 mg, Tab, By Mouth, NOW
			Comment: for pain or dyspnea
		16 mg, Tab, By Mouth, NOW
			Comment: for pain or dyspnea
		20 mg, Tab, By Mouth, NOW
			Comment: for pain or dyspnea
	Decadron injectable
		4 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: for pain or dyspnea
		8 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: for pain or dyspnea
		10 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: for pain or dyspnea
		12 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: for pain or dyspnea
		16 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: for pain or dyspnea
		20 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: for pain or dyspnea
		4 mg, Injection, IV Push, NOW
			Comment: for pain or dyspnea
		8 mg, Injection, IV Push, NOW
			Comment: for pain or dyspnea
		10 mg, Injection, IV Push, NOW
			Comment: for pain or dyspnea
		12 mg, Injection, IV Push, NOW
			Comment: for pain or dyspnea
		16 mg, Injection, IV Push, NOW
			Comment: for pain or dyspnea
		20 mg, Injection, IV Push, NOW
			Comment: for pain or dyspnea
		As needed(NOTE)*
	morphine  oral immediate release
		7.5 mg, Tab, By Mouth, Q1H, PRN, pain-breakthrough
			Comment: or dyspnea
		15 mg, Tab, By Mouth, Q1H, PRN, pain-breakthrough
			Comment: or dyspnea
		30 mg, Tab, By Mouth, Q1H, PRN, pain-breakthrough
			Comment: or dyspnea
	morphine 20 mg/mL oral concentrate
		4 mg, Concentrate, SUBLINGUAL, Q1H, PRN, pain-breakthrough
			Comment: or dyspnea
		5 mg, Concentrate, SUBLINGUAL, Q1H, PRN, pain-breakthrough
			Comment: or dyspnea
		8 mg, Concentrate, SUBLINGUAL, Q1H, PRN, pain-breakthrough
			Comment: or dyspnea
		10 mg, Concentrate, SUBLINGUAL, Q1H, PRN, pain-breakthrough
			Comment: or dyspnea
		15 mg, Concentrate, SUBLINGUAL, Q1H, PRN, pain-breakthrough
			Comment: or dyspnea
		17.5 mg, Concentrate, SUBLINGUAL, Q1H, PRN, pain-breakthrough
			Comment: or dyspnea
		20 mg, Concentrate, SUBLINGUAL, Q1H, PRN, pain-breakthrough
			Comment: or dyspnea
		30 mg, Concentrate, SUBLINGUAL, Q1H, PRN, pain-breakthrough
			Comment: or dyspnea
	Roxicodone
		2.5 mg, Tab, By Mouth, Q4H, PRN, pain-breakthrough
			Comment: or dyspnea
		5 mg, Tab, By Mouth, Q4H, PRN, pain-breakthrough
			Comment: or dyspnea
		10 mg, Tab, By Mouth, Q4H, PRN, pain-breakthrough
			Comment: or dyspnea
	oxyCODONE 20 mg/mL oral concentrate
		2.5 mg, Liquid, SUBLINGUAL, Q1H, PRN, pain-breakthrough
		5 mg, Liquid, SUBLINGUAL, Q1H, PRN, pain-breakthrough
		10 mg, Liquid, SUBLINGUAL, Q1H, PRN, pain-breakthrough
		15 mg, Liquid, SUBLINGUAL, Q1H, PRN, pain-breakthrough
		20 mg, Liquid, SUBLINGUAL, Q1H, PRN, pain-breakthrough
	HYDROmorphone oral
		1 mg, Tab, By Mouth, Q1H, PRN, pain-breakthrough
		2 mg, Tab, By Mouth, Q1H, PRN, pain-breakthrough
			Comment: daily, T+1;0900
		3 mg, Tab, By Mouth, Q1H, PRN, pain-breakthrough
			Comment: daily, T+1;0900
		4 mg, Tab, By Mouth, Q1H, PRN, pain-breakthrough
			Comment: daily, T+1;0900
	morphine  IV
		1 mg, Syringe, IV Push, Q15MIN, PRN, pain-breakthrough
			Comment: or dyspnea. May give if unable to take oral medications.
		2 mg, Syringe, IV Push, Q15MIN, PRN, pain-breakthrough
			Comment: or dyspnea. May give if unable to take oral medications.
		3 mg, Syringe, IV Push, Q15MIN, PRN, pain-breakthrough
			Comment: or dyspnea. May give if unable to take oral medications.
		4 mg, Syringe, IV Push, Q15MIN, PRN, pain-breakthrough
			Comment: or dyspnea. May give if unable to take oral medications.
		5 mg, Syringe, IV Push, Q15MIN, PRN, pain-breakthrough
			Comment: or dyspnea. May give if unable to take oral medications.
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q15MIN, PRN, pain-breakthrough
			Comment: or dyspnea. May give if unable to take oral medications.
		0.4 mg, Injection, IV Push, Q15MIN, PRN, pain-breakthrough
			Comment: or dyspnea. May give if unable to take oral medications.
		0.5 mg, Injection, IV Push, Q15MIN, PRN, pain-breakthrough
			Comment: or dyspnea. May give if unable to take oral medications.
		0.6 mg, Injection, IV Push, Q15MIN, PRN, pain-breakthrough
			Comment: or dyspnea. May give if unable to take oral medications.
		1 mg, Injection, IV Push, Q15MIN, PRN, pain-breakthrough
			Comment: or dyspnea. May give if unable to take oral medications.
	Tylenol
		600 mg, Tab, By Mouth, Q4H, PRN for pain-mild
		650 mg, Suppository, RECTALLY, Q4H, PRN for pain-mild
			Comment: Use suppository if unable to take oral
Nausea Vomiting
		For treatment of nonspecific nausea in palliative care patients, UpToDate recommends haloperidol 1 mg orally or 0.5 mg subcutaneously/IV every six to eight hours as needed. For patients over age 65, UpToDate suggests using a lower dose (0.5 mg orally or 0(NOTE)*
		For patients with gastroparesis, metoclopramide is a reasonable first choice, glucocorticoids may provide benefit for patients with elevated intracranial pressure, and for patients with malignant bowel obstruction, symptomatic improvement may be seen with(NOTE)*
		As Needed(NOTE)*
	Haldol  Oral
		0.5 mg, Tab, By Mouth, Q4H, PRN, nausea
		1 mg, Tab, By Mouth, Q4H, PRN, nausea
		2 mg, Tab, By Mouth, Q4H, PRN, nausea
	Reglan 10 mg oral tablet
		1 TAB, By Mouth, Q6H, PRN, nausea
	ondansetron
		4 mg, Tablet-Disintegrating, By Mouth, Q8H, PRN for nausea
			Comment: for nausea
		8 mg, Tablet-Disintegrating, By Mouth, Q8H, PRN for nausea
			Comment: for nausea
	Benadryl
		25 mg, Capsule, By Mouth, Q4H, PRN, nausea
	Haldol  injectable
		0.5 mg, Injection, IV Push, Q4H, PRN, nausea
			Comment: May give if unable to take oral medications. MJE only: Patient does not need continuous cardiac monitoring.
		1 mg, Injection, IV Push, Q4H, PRN, nausea
			Comment: May give if unable to take oral medications. MJE only: Patient does not need continuous cardiac monitoring.
		2 mg, Injection, IV Push, Q4H, PRN, nausea
			Comment: May give if unable to take oral medications. MJE only: Patient does not need continuous cardiac monitoring.
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN, nausea
			Comment: may give if unable to take oral medications.
	ondansetron
		4 mg, Injection, IV PUSH, Q8H, PRN for nausea
			Comment: may give if unable to take oral medications
		8 mg, Injection, IV PUSH, Q8H, PRN for nausea
			Comment: may give if unable to take oral medications
		10 mg, INT, IVPB, Q8H, PRN for nausea
			Comment: may give if unable to take oral medications
	Benadryl
		25 mg, Injection, IV Push, Q4H, PRN, nausea
			Comment: may give if unable to take oral medications
		Scheduled(NOTE)*
	Haldol  Oral
		0.5 mg, Tab, By Mouth, Q4H
			Comment: for nausea
		1 mg, Tab, By Mouth, Q4H
			Comment: for nausea
		2 mg, Tab, By Mouth, Q4H
			Comment: for nausea
	Haldol  injectable
		0.5 mg, Injection, IV, Q4H
			Comment: for nausea. MJE ONLY patient does not need continuous cardiac monitoring.
		1 mg, Injection, IV, Q4H
			Comment: for nausea. MJE ONLY patient does not need continuous cardiac monitoring.
		2 mg, Injection, IV, Q4H
			Comment: for nausea. MJE ONLY patient does not need continuous cardiac monitoring.
	Reglan 10 mg oral tablet
		1 TAB, By Mouth, Q6H
			Comment: for nausea
	Reglan
		10 mg, Injection, IV Push, Q6H
			Comment: for nausea
	ondansetron
		4 mg, Tablet-Disintegrating, By Mouth, Q8H
			Comment: for nausea
		8 mg, Tablet-Disintegrating, By Mouth, Q8H
			Comment: for nausea
		4 mg, Injection, IV PUSH, Q8H
			Comment: for nausea
		8 mg, Injection, IV PUSH, Q8H
			Comment: for nausea
	dexAMETHasone
		4 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: nausea adjunct
		8 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: nausea adjunct
		10 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: nausea adjunct
		12 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: nausea adjunct
		16 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: nausea adjunct
		20 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: nausea adjunct
		4 mg, Tab, By Mouth, NOW
			Comment: nausea adjunct
		8 mg, Tab, By Mouth, NOW
			Comment: nausea adjunct
		10 mg, Tab, By Mouth, NOW
			Comment: nausea adjunct
		12 mg, Tab, By Mouth, NOW
			Comment: nausea adjunct
		16 mg, Tab, By Mouth, NOW
			Comment: nausea adjunct
		20 mg, Tab, By Mouth, NOW
			Comment: nausea adjunct
	Decadron injectable
		4 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: nausea adjunct
		8 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: nausea adjunct
		10 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: nausea adjunct
		12 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: nausea adjunct
		16 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: nausea adjunct
		20 mg, Injection, IV Push, DAILY, T+1;0900
			Comment: nausea adjunct
		4 mg, Injection, IV Push, NOW
			Comment: nausea adjunct
		8 mg, Injection, IV Push, NOW
			Comment: nausea adjunct
		10 mg, Injection, IV Push, NOW
			Comment: nausea adjunct
		12 mg, Injection, IV Push, NOW
			Comment: nausea adjunct
		16 mg, Injection, IV Push, NOW
			Comment: nausea adjunct
		20 mg, Injection, IV Push, NOW
			Comment: nausea adjunct
Dyspnea
		As Needed(NOTE)*
	albuterol 2.5 mg/3 mL (0.083%) inh soln
		3 mL, Solution-Nebulization, NEBULIZED, Q4H-Sch, PRN, wheezing
	Oxygen Therapy for Comfort Care Patient
		T;N, Via Nasal Cannula, PRN
			Comment: O2 @ 1L/min
		T;N, Via Nasal Cannula, PRN
			Comment: O2 @ 2L/min
		T;N, Via Nasal Cannula, PRN
			Comment: O2 @ 3L/min
		T;N, Via Nasal Cannula, PRN
			Comment: O2 @ 4L/min
Cough
		As Needed(NOTE)*
	chlorpheniramine-hydrocodone 8 mg-10 mg/5 mL oral suspension, extended release
		5 mL, Suspension, Extended-Release, By Mouth, Q8H, PRN for cough
	benzonatate
		100 mg, Capsule, By Mouth, Q6H, PRN for cough
	Mucinex
		600 mg, Tablet-Extended-Release, By Mouth, Q6H, PRN, cough
Constipation
		Scheduled(NOTE)*
	Senokot S 50 mg-8.6 mg oral tablet
		1 TAB, Tab, By Mouth, BID
			Comment: for constipation
		2 TAB, Tab, By Mouth, BID
			Comment: for constipation
		3 TAB, Tab, By Mouth, BID
			Comment: for constipation
		4 TAB, Tab, By Mouth, BID
			Comment: for constipation
		As Needed(NOTE)*
		1 TAB, Tab, By Mouth, Q12H, PRN, constipation
		2 TAB, Tab, By Mouth, Q12H, PRN, constipation
		3 TAB, Tab, By Mouth, Q12H, PRN, constipation
		4 TAB, Tab, By Mouth, Q12H, PRN, constipation
		1 TAB, Tab, By Mouth, Q24H, PRN, constipation
		2 TAB, Tab, By Mouth, Q24H, PRN, constipation
		3 TAB, Tab, By Mouth, Q24H, PRN, constipation
		4 TAB, Tab, By Mouth, Q24H, PRN, constipation
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN, constipation
Diarrhea
		As Needed(NOTE)*
	Imodium
		2 mg, Capsule, By Mouth, Q6H, PRN, diarrhea
	Lomotil
		1 TAB, Tab, By Mouth, Q4H, PRN, diarrhea
			Comment: 2 tabs PRN, then 1 tab PRN after each loose stool; max 8 tabs/day
Delirium
		Scheduled(NOTE)*
	Haldol  Oral
		1 mg, Tab, By Mouth, Q4H
			Comment: for delirium
		2 mg, Tab, By Mouth, Q4H
			Comment: for delirium
		3 mg, Tab, By Mouth, Q4H
			Comment: for delirium
		4 mg, Tab, By Mouth, Q4H
			Comment: for delirium
	Haldol 2 mg/mL oral concentrate
		1 mg, Concentrate, SUBLINGUAL, Q4H
			Comment: for delirium
		2 mg, Concentrate, SUBLINGUAL, Q4H
			Comment: for delirium
		3 mg, Concentrate, SUBLINGUAL, Q4H
			Comment: for delirium
		4 mg, Concentrate, SUBLINGUAL, Q4H
			Comment: for delirium
		5 mg, Concentrate, SUBLINGUAL, Q4H
			Comment: for delirium
	Haldol  injectable
		1 mg, Injection, IV Push, Q4H
			Comment: for delirium MJE only: Patient does not need continuous cardiac monitoring.
		2 mg, Injection, IV Push, Q4H
			Comment: for delirium MJE only: Patient does not need continuous cardiac monitoring.
		3 mg, Injection, IV Push, Q4H
			Comment: for delirium MJE only: Patient does not need continuous cardiac monitoring.
		4 mg, Injection, IV Push, Q4H
			Comment: for delirium MJE only: Patient does not need continuous cardiac monitoring.
		5 mg, Injection, IV Push, Q4H
			Comment: for delirium MJE only: Patient does not need continuous cardiac monitoring.
	Ativan
		0.5 mg, By Mouth, Q4H
			Comment: for delirium
		1 mg, By Mouth, Q4H
			Comment: for delirium
		2 mg, By Mouth, Q4H
			Comment: for delirium
		3 mg, By Mouth, Q4H
			Comment: for delirium
	LORazepam Oral Concentrate
		1 mg, Concentrate, SUBLINGUAL, Q4H
			Comment: for delirium
		2 mg, Concentrate, SUBLINGUAL, Q4H
			Comment: for delirium
		3 mg, Concentrate, SUBLINGUAL, Q4H
			Comment: for delirium
	Ativan Injectable
		0.5 mg, Injection, IV Push, Q4H
			Comment: for delirium
		1 mg, Injection, IV Push, Q4H
			Comment: for delirium
		2 mg, Injection, IV Push, Q4H
			Comment: for delirium
		3 mg, Injection, IV Push, Q4H
			Comment: for delirium
		As Needed(NOTE)*
	Haldol  Oral
		1 mg, Tab, By Mouth, Q1H, PRN, agitation
		2 mg, Tab, By Mouth, Q1H, PRN, agitation
		3 mg, Tab, By Mouth, Q1H, PRN, agitation
		4 mg, Tab, By Mouth, Q1H, PRN, agitation
		5 mg, Tab, By Mouth, Q1H, PRN, agitation
		1 mg, Tab, By Mouth, Q2H, PRN, agitation
		2 mg, Tab, By Mouth, Q2H, PRN, agitation
		3 mg, Tab, By Mouth, Q2H, PRN, agitation
		4 mg, Tab, By Mouth, Q2H, PRN, agitation
		5 mg, Tab, By Mouth, Q2H, PRN, agitation
		1 mg, Tab, By Mouth, Q4H, PRN, agitation
		2 mg, Tab, By Mouth, Q4H, PRN, agitation
		3 mg, Tab, By Mouth, Q4H, PRN, agitation
		4 mg, Tab, By Mouth, Q4H, PRN, agitation
		5 mg, Tab, By Mouth, Q4H, PRN, agitation
	Haldol 2 mg/mL oral concentrate
		1 mg, Concentrate, SUBLINGUAL, Q1H, PRN, delirium
		2 mg, Concentrate, SUBLINGUAL, Q1H, PRN, delirium
		3 mg, Concentrate, SUBLINGUAL, Q1H, PRN, delirium
		4 mg, Concentrate, SUBLINGUAL, Q1H, PRN, delirium
		5 mg, Concentrate, SUBLINGUAL, Q1H, PRN, delirium
		1 mg, Concentrate, SUBLINGUAL, Q2H, PRN, delirium
		2 mg, Concentrate, SUBLINGUAL, Q2H, PRN, delirium
		3 mg, Concentrate, SUBLINGUAL, Q2H, PRN, delirium
		4 mg, Concentrate, SUBLINGUAL, Q2H, PRN, delirium
		5 mg, Concentrate, SUBLINGUAL, Q2H, PRN, delirium
		1 mg, Concentrate, SUBLINGUAL, Q4H, PRN, delirium
		2 mg, Concentrate, SUBLINGUAL, Q4H, PRN, delirium
		3 mg, Concentrate, SUBLINGUAL, Q4H, PRN, delirium
		4 mg, Concentrate, SUBLINGUAL, Q4H, PRN, delirium
		5 mg, Concentrate, SUBLINGUAL, Q4H, PRN, delirium
	Ativan
		0.5 mg, By Mouth, Q1H, PRN, delirium
		1 mg, By Mouth, Q1H, PRN, delirium
		2 mg, By Mouth, Q1H, PRN, delirium
		3 mg, By Mouth, Q1H, PRN, delirium
		0.5 mg, By Mouth, Q2H, PRN, delirium
		1 mg, By Mouth, Q2H, PRN, delirium
		2 mg, By Mouth, Q2H, PRN, delirium
		3 mg, By Mouth, Q2H, PRN, delirium
		0.5 mg, By Mouth, Q4H, PRN, delirium
		1 mg, By Mouth, Q4H, PRN, delirium
		2 mg, By Mouth, Q4H, PRN, delirium
		3 mg, By Mouth, Q4H, PRN, delirium
	LORazepam Oral Concentrate
		0.5 mg, Concentrate, SUBLINGUAL, Q1H, PRN, delirium
		1 mg, Concentrate, SUBLINGUAL, Q1H, PRN, delirium
		2 mg, Concentrate, SUBLINGUAL, Q1H, PRN, delirium
		3 mg, Concentrate, SUBLINGUAL, Q1H, PRN, delirium
		0.5 mg, Concentrate, SUBLINGUAL, Q2H, PRN, delirium
		1 mg, Concentrate, SUBLINGUAL, Q2H, PRN, delirium
		2 mg, Concentrate, SUBLINGUAL, Q2H, PRN, delirium
		3 mg, Concentrate, SUBLINGUAL, Q2H, PRN, delirium
		0.5 mg, Concentrate, SUBLINGUAL, Q4H, PRN, delirium
		1 mg, Concentrate, SUBLINGUAL, Q4H, PRN, delirium
		2 mg, Concentrate, SUBLINGUAL, Q4H, PRN, delirium
		3 mg, Concentrate, SUBLINGUAL, Q4H, PRN, delirium
	Haldol  injectable
		1 mg, Injection, IV Push, Q1H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		2 mg, Injection, IV Push, Q1H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		3 mg, Injection, IV Push, Q1H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		4 mg, Injection, IV Push, Q1H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		5 mg, Injection, IV Push, Q1H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		1 mg, Injection, IV Push, Q2H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		2 mg, Injection, IV Push, Q2H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		3 mg, Injection, IV Push, Q2H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		4 mg, Injection, IV Push, Q2H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		5 mg, Injection, IV Push, Q2H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		1 mg, Injection, IV Push, Q4H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		2 mg, Injection, IV Push, Q4H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		3 mg, Injection, IV Push, Q4H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		4 mg, Injection, IV Push, Q4H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
		5 mg, Injection, IV Push, Q4H, PRN, delirium
			Comment: may give if unable to give oral medications. MJE only: patient does not need continuous cardiac monitoring
	Ativan Injectable
		0.5 mg, Injection, IV Push, Q1H, PRN, delirium
			Comment: may give if unable to give oral medications
		1 mg, Injection, IV Push, Q1H, PRN, delirium
			Comment: may give if unable to give oral medications
		2 mg, Injection, IV Push, Q1H, PRN, delirium
			Comment: may give if unable to give oral medications
		3 mg, Injection, IV Push, Q1H, PRN, delirium
			Comment: may give if unable to give oral medications
		0.5 mg, Injection, IV Push, Q2H, PRN, delirium
			Comment: may give if unable to give oral medications
		1 mg, Injection, IV Push, Q2H, PRN, delirium
			Comment: may give if unable to give oral medications
		2 mg, Injection, IV Push, Q2H, PRN, delirium
			Comment: may give if unable to give oral medications
		3 mg, Injection, IV Push, Q2H, PRN, delirium
			Comment: may give if unable to give oral medications
		0.5 mg, Injection, IV Push, Q4H, PRN, delirium
			Comment: may give if unable to give oral medications
		1 mg, Injection, IV Push, Q4H, PRN, delirium
			Comment: may give if unable to give oral medications
		2 mg, Injection, IV Push, Q4H, PRN, delirium
			Comment: may give if unable to give oral medications
		3 mg, Injection, IV Push, Q4H, PRN, delirium
			Comment: may give if unable to give oral medications
Dyspepsia
		Scheduled(NOTE)*
	Pepcid
		20 mg, Tab, By Mouth, BID
		20 mg, Injection, IV Push, BID
	Protonix
		40 mg, Tablet-Enteric-Coated, By Mouth, DAILY
		40 mg, Injection, IV Push, Q24H
		As Needed(NOTE)*
	sucralfate 1 g/10 mL oral suspension
		2 gm, Suspension, By Mouth, QID, PRN, dyspepsia
	aluminum hydroxide/magnesium hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL oral susp
		30 mL, Suspension-Oral, By Mouth, Q12H, PRN for dyspepsia
Anxiety
		For symptomatic management of acute delirium, UpToDate recommends initiating haloperidol at 2 mg orally or 1 mg subcutaneously/IV every two hours until settled, then every six or eight hours as needed. A 50 percent dose reduction is recommended for the el(NOTE)*
		For management of anxiety or terminal agitation UpToDate prefers lorazepam, starting at 1 mg orally or subcutaneously/IV every six hours as needed. Delirium can sometimes be mistaken for anxiety, but delirium is better managed with haloperidol.(NOTE)*
		As Needed(NOTE)*
	Ativan
		0.5 mg, Tab, By Mouth, Q1H, PRN, anxiety
		1 mg, Tab, By Mouth, Q1H, PRN, anxiety
		2 mg, Tab, By Mouth, Q1H, PRN, anxiety
	LORazepam Oral Concentrate
		0.5 mg, Concentrate, SUBLINGUAL, Q1H, PRN, anxiety
		1 mg, Concentrate, SUBLINGUAL, Q1H, PRN, anxiety
		2 mg, Concentrate, SUBLINGUAL, Q1H, PRN, anxiety
	Ativan Injectable
		0.5 mg, Injection, IV Push, Q1H, PRN, anxiety
		1 mg, Injection, IV Push, Q1H, PRN, anxiety
		2 mg, Injection, IV Push, Q1H, PRN, anxiety
Seizures
		For seizure control until a physician is consulted for ongoing orders.(NOTE)*
	Ativan
		2 mg, Injection, IV Push, Q5MIN, PRN, seizure activity, 2 Dose(s)/Time(s)
			Comment: Notify MD if seizure activity
		2 mg, Injection, SUBCUTANEOUS, Q5MIN, PRN, seizure activity, 2 Dose(s)/Time(s)
			Comment: Notify MD if seizure activity
Secretions
		Use of glycopyrrolate is generally preferred over atropine and scopolamine hydrobromide (tertiary amines) because of less central effects; the molecular structure of glycopyrrolate, a quaternary compound, impedes entry across the blood brain barrier.(NOTE)*
	glycopyrrolate
		0.2 mg, Injection, IV Push, Q4H, PRN, secretions
			Comment: PRN Terminal Secretions
		0.4 mg, Injection, IV Push, Q4H, PRN, secretions
			Comment: PRN Terminal Secretions
	atropine 1% ophthalmic solution
		3 gtt, Solution, SUBLINGUAL, Q2H, PRN, secretions
	Levsin
		0.125 mg, SUBLINGUAL, Q4H, PRN, secretions
		0.25 mg, SUBLINGUAL, Q4H, PRN, secretions
Fever
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN, temperature >  (see comment)
			Comment: 100F
		650 mg, Suppository, RECTALLY, Q4H, PRN, temperature >  (see comment)
			Comment: 100F. may give if unable to take oral medications
Sleep
	Ambien
		5 mg, Tab, By Mouth, QHS, PRN, insomnia
			Comment: May repeat once to max dose of 10mg per night. Notify MD if ineffective after second dose
	traZODone
		25 mg, Tab, By Mouth, QHS, PRN, insomnia
		50 mg, Tab, By Mouth, QHS, PRN, insomnia
Mucous Membrane Care
		Attention to mouth care is essential, and the family can be encouraged to give sips of water or moisten the patients mouth with a swab. Glycerine is no longer recommended as it is thought to cause drying.(NOTE)*
		Scheduled(NOTE)*
	nystatin  100,000 units/mL oral suspension
		5 mL, Suspension, By Mouth, Q6H, Candida invasive
		As Needed(NOTE)*
	magic mouthwash
		10 mL, Suspension, MOUTHWASH, Q4H, PRN, oral care
			Comment: for mouth sore, pain. Swish and spit or swallow
	lidocaine Viscous 2% solution
		10 mL, Solution, By Mouth, Q4H, PRN, oral care
			Comment: Swish and spit or swallow
	Artificial Tears ophthalmic solution
		1 gtt, Solution, Eye, Affected, Q30MIN, PRN for dry eyes
	phenazopyridine
		200 mg, Tab, By Mouth, TID, PRN for urinary discomfort
	Chloraseptic Menthol 1.4% topical spray
		1 spray, Spray, TOPICAL, Q30MIN, PRN for sore throat
Patient Care

	Discontinue
		Pulse oximetry
	Discontinue Cardiac Telemetry Monitoring
		
	Discontinue
		Monitor in room
	Discontinue Central Line
		
	Do Not
		Restart IV fluids if infiltrates
	Discontinue IV Fluids
		See Order Comments
			Comment: maintenance/continuous fluids
	Discontinue Medication
		vasopressors, titrate off slowly
	Discontinue Enteral Tube
		
	Foley Catheter
		T;N, Foley, Insert, Comfort care/end-of-life, PRN, as desired, as needed
	Notify
		All providers of comfort care status prior to initiation of comfort care
	Discontinue Anti Embolism Device
		T;N
			Comment: venodynes/teds
	Discontinue Lab
		T;N
			Comment: Comment: all routine lab and radiology except POC glucose
	Discontinue
		T;N, POC glucose
	Notify MD
		T;N, for direction in POC glucose testing and treatment if diabetic
	Discontinue
		T;N, Oxygen protocol and respiratory protocol
		T;N, Pulse oximetry checks
	Notify
		T;N, Respiratory therapy for daily oxygen checks and charges
	Verify No Code/DNR order has been obtained from MD
		
	VTE Prophylaxis Contraindication
		Comfort Cares
Therapies
		The routine administration of oxygen to patients who are near death is not supported by clinical evidence. The use of supplemental oxygen should ideally be restricted to dyspneic patients who are hypoxemic. In this setting, oxygen masks are not generally(NOTE)*
	Oxygen Therapy for Comfort Care Patient
		T;N
Consults/Follow-up
		Terminally ill patients suffering from severe distress should be evaluated urgently, preferably by a palliative care clinician.(NOTE)*
	Consult Dietitian
		Regarding: Comfort Care
	Consult Chaplain
		T;N, Adult end of life/comfort care
			Comment: Comfort Care order set initiated
		T;N, No one dies alone
			Comment: to initiate "No one dies alone" volunteer service
	Consult Social Work
		T;N
			Comment: Hospice Care- GIP evaluation

scopolamine (Transderm-Scop) 1 mg patch
Medications
	Transderm-Scop 1 mg patch
		1 mg, Patch, TOPICAL, Q3D
	scopolamine Patch Removal
		Patch Removal, Patch, TOPICAL, Q3D, T+3;0900
Patient Care
	Medication patch site check
		T;N+720, Q12H

Constipation Protocol
Medications
	MiraLax oral powder for reconstitution
		17 gm, Packet, BY MOUTH, Q12H, PRN, constipation
			Comment: Mix in 6 oz of juice or water.
		17 gm, Packet, BY MOUTH, DAILY, PRN, constipation
			Comment: Mix in 6 oz juice or water
	Milk of Magnesia 8% oral suspension
		30 mL, Suspension, By Mouth, DAILY, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
		30 mL, Suspension, By Mouth, Q12H, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
	Dulcolax
		10 mg, Suppository, RECTALLY, DAILY, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
		10 mg, Suppository, RECTALLY, Q12H, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, DAILY, PRN, constipation
			Comment: If bisacodyl ineffective
Patient Care
	Notify MD
		if no results from enema.
	Enema-Administer
		T;N, Tap water, Q12H constipation
			Comment: PRN,  if suppository ineffective

PCA hydromorphone (Dilaudid)
IV Solutions
	Sodium Chloride 0.9%
		500 mL, IV, 20 ml/hr
			Comment: If no current IV fluid order.
Medications
		Standard protocol w/basal(NOTE)*
	Dilaudid Injectable
		0.5 mg, Injection, IV PUSH, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 30mL Standard IV
		Continuous Dose (mg/hr) 0 - 0.2 mg/hr, Patient Admin Bolus (mg) 0.1 - 0.2 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 3, Nurse Admin Bolus (mg) 0.2 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 30 mL, PCA IV, PCA
			Comment: Adjust to patient's documented individual pain goal.  For continuous dosing, begin with no basal for mild/moderate pain; 0.1mg/hr for severe pain; adjust rate by 0.1mg/hr q30min up to a maximum of 0.2mg/hr as needed for moderate or severe pain (pain score>3) and down 0.1mg/hr q30 min as needed for mild or moderate.  DC basal rate if dose required is less than 0.1mg/hr (side effects present) and use patient controlled dosing only.  For patient controlled dose, start at 0.1mg for mild/moderate pain adjust by 0.1mg q30min up to a maximum of 0.2mg, For patient controlled dose, start at 0.2mg for severe pain and adjust by 0.1mg down q30 min as needed for mild or moderate pain. Dose adjustment of EITHER the continuous or patient administered dose may occur every 30 minutes, do not adjust both continuous or PCA dose at the same time (exception for comfort care patients)-  Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, discontinue basal if running, and restart patient controlled dose at 0.1mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		6 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
		Standard protocol NO basal(NOTE)*
	Dilaudid Injectable
		0.5 mg, Injection, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 30mL Standard IV
		Continuous Dose (mg/hr) No basal rate, Patient Admin Bolus (mg) 0.1 - 0.2 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 3 mg, Nurse Admin Bolus (mg) 0.2 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 30 mL, PCA IV, PCA
			Comment: STANDARD-NO BASAL.  .Adjust to patient's documented individual pain goal. Start patient controlled dose at 0.1mg for mild/moderate pain, and adjust by 0.1mg up to a maximum of 0.2mg or down q30min as needed for moderate or severe pain (pain score >3), Start patient controlled dose at 0.2mg for severe pain and adjust down by 0.1mg q30min as needed for mild/moderate pain.-  Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, restart patient controlled dose at 0.1mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		6 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
		High risk(NOTE)*
	Dilaudid Injectable
		0.3 mg, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 30mL Standard IV
		Continuous Dose (mg/hr) No basal rate, Patient Admin Bolus (mg) 0.1 - 0.2 mg, Lockout Interval (min) = 15, 4-hour Limit (mg) 2 mg, Nurse Admin Bolus (mg) 0.2 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 30 mL, PCA IV, PCA
			Comment: HIGH RISK PROTOCOL. Adjust to patient's documented individual pain goal. Start at 0.1mg and adjust by 0.1mg q30min to a maximum of 0.2mg as needed for moderate or severe pain (pain score >3). -  Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding,, and restart patient controlled dose at 0.1mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		6 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
		Opiate tolerant(NOTE)*
	Dilaudid Injectable
		1 mg, Injection, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 30mL Standard IV
		Continuous Dose (mg/hr) 0.3 - 0.6 mg/hr, Patient Admin Bolus (mg) 0.1 - 0.5 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 4 mg, Nurse Admin Bolus (mg) 0.3 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 30 mL, PCA IV
			Comment: OPIATE TOLERANT PROTOCOL. Adjust to patient's documented individual pain goal. Start at 0.3mg/hr and adjust dose by 0.1mg/hr up to a maximum of 0.6mg/hr q30min as needed for moderate or severe pain (pain score >3) and down by 0.1mg/hr q30min as needed for mild or moderate pain; Patient controlled dose start at 0.2mg and increase by 0.1mg q30min up to a maximum of 0.5mg as needed for moderate or severe pain (pain score >3) or decrease by 0.1mg q30min as needed for mild or moderate pain. Dose adjustment of EITHER the continuous or patient administered dose may occur every 30 minutes do not adjust both continuous or PCA dose at the same time (exception for comfort care patients) - Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, discontinue basal if running, and decrease patient controlled dose at 0.2mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		6 mg, EVERY BAG, 0.3 mg/hr
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
	Narcan
		0.1 mg, Injection, IV Push, Q5MIN, PRN, see comment
			Comment: Until desired response.  Follow with 10 mL NaCl Flush, for patients who are somnolent with minimal or no response to stimuli, RASS -3 to -5, or for respiratory rate less than or equal to 10/minute, notify physician while on PCA protocol.
Patient Care
	PCA Assessment
		T;N, Q15MIN, 4, Dose(s)/Time(s)
			Comment: Assessment to include vital signs, pain, RASS, resp rate, resp pattern, pump settings, and ETCO2 if appropriate.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N+60, Q1H, 4, Dose(s)/Time(s)
			Comment: Assessment to include vital signs, pain, RASS, resp rate, resp pattern, pump settings, and ETCO2 if appropriate. Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N+420, Q2H-Sch
			Comment: Assessment to include vital signs, pain, RASS, resp rate, resp pattern, pump settings, and ETCO2 if appropriate. Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N
			Comment: ongoing, with any patient controlled dose, basal rate change or nurse administered bolus. Assessment to include vital signs, pain, RASS, resp rate, resp pattern and pump settings. If resp rate <10, or SBP <90 reassess patient q15min x4, then q1h x4, then q2h.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N
	Notify MD
		T;N, if patient is on benzodiazepines (lorazepam, midazolam, diazepam etc.)
		T;N, if respirations </= 10, or  systolic BP < 90.
		T;N, if pain increases or unable to wean in 12 hr
		T;N, if ETCO2 greater than 50
	PCA Parameters
		T;N
			Comment: Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR < or = 12bpm and normal depth, alert.  Consider oxygen protocol.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		T;N
			Comment: Do not initiate any PCA (continuous or patient administered doses) in patients with sleep apnea (OSA) without verbal verification from physician.  Basal (continuous) PCA dosing should not be used for patients with history of sleep apnea (OSA), or respiratory problems (lung disease, heart failure). Do not use patient controlled doses of PCA unless patient is fully able to understand and comply with instruction -this includes restricting use for patients with dementia, delirium, confusion. Start dosing at the lowest range possible for continuous and patient administered doses (exceptions comfort care patients, oncology patients routinely receiving opiates, chronic pain patient routinely receiving opiates), including starting with no basal rate.
	PCA weaning parameters
		T;N
			Comment: 1.  Administer oral opiate.2.  Provide patient education on weaning process3.  If a basal (continuous) rate is running, turn it off upon administration of oral opiate4.  Begin demand (patient controlled dose) wean 4hr after initial opiate dose.  Every 4hr decrease demand dose by 50% until adequate pain control is achieved (defined as a pain scale of <4 or meeting patient's goal for pain control).  Do not decrease demand below minimum dose in PCA protocol for patient controlled dosing (0.5mg morphine, 0.1mg hydromorphone)5.  If patient does not use demand dose in at least 4hr after receiving oral medication, discontinue PCA.6.  Notify MD if pain increases or unable to wean in 12hr.
Therapies
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
			Comment: RT, while on PCA

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase